- Email: [email protected]
Health Services Research Agenda for Clinical Preventive Services
Health Services Research Agenda for Clinical Preventive Services James K. Cooper, MD, Carolyn M. Clancy, MD
Medical Subject Headings (MeSH): preventive health services, Agency for Health Care Policy and Research (AHCPR), cost effectiveness, quality assessment (health care). (Am J Prev Med 1998;14:331–334) © 1998 American Journal of Preventive Medicine
D
uring the national health care reform debate in the 103rd Congress, all major proposals included specific clinical preventive services as important and explicitly defined benefits. The proposed Health Security Act, for example, carefully defined a benefit package with selected clinical preventive services. Even more modest proposals frequently specified elimination of co-payments for preventive care. While no health care reform legislation was passed by the 103rd Congress, support for preventive services, in one way or another, was one of the few nearly universally accepted goals. Today, health care purchasers and consumers appear to be demanding more accountability in health care delivery systems.1 There is growing interest in reporting health care plan performance, including performance of clinical preventive services. For example, the Healthplan Employer Data and Information System (HEDIS) is used by many managed care plans, and is being required for Medicare managed care plans.2 HEDIS includes data on a significant number of clinical preventive services, such as immunizations, mammography, lipid screening, and cervical cancer screening. Comparisons among plans can be made by potential purchasers and consumers. Plans are competing in terms of clinical prevention as well as acute care services and cost. A new focus on these preventive services is provided by the rapid increase in the proportion of Americans receiving care in organized delivery systems. Although other services, such as counseling and injury prevention, have not received the same attention, preventive care, nevertheless, remains in the national spotlight. Health care organizations that are accountable for providing care to a defined population would appear to have a vested interest in shifting the focus of medical care to one that keeps individuals as healthy as possible. Center for Primary Care Research, Agency for Health Care Policy and Research, Rockville, Maryland 20852. Address correspondence to: Dr. James K. Cooper, CPCR/AHCPR, 2101 E. Jefferson Street, Rockville, Maryland 20852.
Am J Prev Med 1998;14(4) © 1998 American Journal of Preventive Medicine
On the other hand, rapid enrollee turnover may lessen managed care’s interest in preventive services, as the benefits may not accrue until years later, when the enrollee may be in another plan. Fierce competition among plans may require them to focus on current cost reduction rather than on long-term benefits. And even if they did focus on future costs, preventive services do not always produce reduced health care costs.3 Preventive services may not expand under managed care unless they are both demanded by purchasers, and can be provided at reasonable cost. While there appears to be national interest in making preventive services widely available, there is, then, also great interest in making them efficient, i.e., making them produce the most good for the least cost. This goal fits into the rubric of health services research. The Agency for Health Care Policy and Research (AHCPR) is the lead agency for health services research in the Department of Health and Human Services. Building on a foundation established by its predecessor, the National Center for Health Services Research, AHCPR has supported studies that identify ways to increase the delivery and efficiency of recommended clinical preventive services.4 In general, clinical preventive services are prevention services offered or initiated in the personal health care setting. Examples include immunizations, disease screening, counseling to reduce health risks, and chemoprophylaxis after exposure to infectious disease. AHCPR-supported studies have focused on a variety of clinical preventive services issues. One study examined barriers to receiving preventive services.5 Another AHCPR-supported study explored ways to increase private physician participation in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, helping to bring the benefits of a public prevention program to children seen in physicians’ offices.6 Other AHCPR-supported studies currently underway include the development of strategies to encourage primary care practitioners to increase the provision of recommended prevention services.
0749-3797/98/$19.00 PII S0749-3797(97)00056-1
331
As the rapid shift to organized systems of care heightens interest in the delivery of clinical preventive services, AHCPR invites researchers to submit proposals that further this purpose by helping translate diseaseprevention knowledge into improved and more efficient clinical preventive services.7 As health care evolves, a diversity of approaches to clinical preventive services can be expected. This offers a setting for many natural experiments, and researchers should have many opportunities to evaluate benefits of new approaches.
Research Goals AHCPR is interested in effectiveness research. The framework separating “effectiveness” from “efficacy” dates back to at least 1978, when the Office of Technology Assessment issued a report on the efficacy and safety of medical technologies.8 In this framework, “efficacy” refers to the probability of benefit under ideal conditions, and “effectiveness” refers to benefit that can be expected in typical “everyday” situations. This framework has been useful in separating clinical research into two categories and helps align investigators with appropriate funding agencies. While not all federal agencies dichotomize clinical research this way (the Food and Drug Administration has a broad definition of effectiveness that includes efficacy), AHCPR encourages health services research proposals on efficacy-proven clinical preventive services, not research on preventive services for which efficacy has not yet been established. Factors that can change the probability of benefit of interventions “in the real world,” and thus also their effectiveness, include provider behaviors, skills, and techniques; and patient adherence/compliance and other characteristics. Organizational characteristics such as context, institutional values, incentives, control, and external relationships may affect the benefit of preventive services by increasing the proportion of targeted people receiving the intervention. Organizational characteristics may also affect costs. Recommendations for clinical preventive services are presented in the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services.9 The U.S. Preventive Services Task Force was established in 1984 to develop evidence-based guidelines for preventive care, and their recommendations provide a blueprint for action.10 While efficacy of these clinical preventive services is generally accepted, the aggregate community benefit of many prevention programs has been disappointing. AHCPR hopes to support research that leads to improved effectiveness and efficiency of clinical preventive services in the community. Research is sought in three areas. These areas are interrelated, and research may address one, two, or all three areas.
332
Effectiveness and Cost-Effectiveness There is no question that cost has become an important consideration in the delivery of health care. It is unrealistic to imagine that all preventive services should be offered to all individuals. Cost constraints and movement toward competitive contracting for clinical services increase the need for reliable and acceptable cost-effectiveness data. Groups that purchase or pay for health care, such as corporations and purchaser alliances, need information on the effectiveness and costs of preventive services, and the way they are provided, in order to make informed decisions as to what to purchase. Provider groups need information about effectiveness and ways to lower the costs of individual preventive services. Coverage for services, components of bundled services, and exclusions of services may be determined on the basis of cost-effectiveness and outcomes analyses. Cost-effectiveness studies examine the cost of alternatives to achieve a desired goal. Costs include direct medical costs and indirect costs, which include psychological costs. Psychological costs may include pain, fear, apprehension, and perhaps loss of gratifying behaviors. Effectiveness relates to patient outcomes, and may include outcomes other than morbidity or mortality, such as functional status and quality of life. Cost savings from preventive services are particularly difficult to evaluate, because the expected gain from an intervention may be in the extended future, and many other variables are likely to intervene. The value of a future savings is difficult to assess due to disagreement on discounting.11 The public’s discount rates for some serious outcomes, such as colostomy and blindness, are much less than the usual discount rates used by economists, meaning people assign a high value to avoiding them in the future as well as the present. But discount rates also have shown dynamic inconsistency bias; discounts for long delays can be lower than for short delays.12,13 In other words, in some cases, individuals appear to value a health benefit more in the distant future than in the near future. Understanding how people value their future health can assist in planning clinical preventive programs that preserve future health. Important research in this area would include: costeffectiveness of specific preventive services; cost-effectiveness comparison of practice standards and recommendations, comparing different methods for the delivery of preventive services currently suggested by various organizations; and effects of different practice management patterns on cost-effectiveness of clinical preventive services. Another important research issue is the cost-effectiveness of different approaches to counseling and health
American Journal of Preventive Medicine, Volume 14, Number 4
education services. An example is the question, how useful are approaches that use non-physician providers? Corporate and other large purchasers may negotiate with provider groups for “packages” of preventive services. The services may be “bundled” for consideration. Evaluation of bundling preventive services, including cost-effectiveness of various preventive service packages, is an important topic. The interaction of combinations of services is virtually unstudied. For example, does an intense cholesterol control program have any effect on a simultaneous cancer control program? In addition to dollar costs, preventive services should be evaluated in other dimensions as well. Methods for assessing outcomes of clinical preventive services that incorporate quality-of-life measures and patient preferences into standardized methods of comparison are important. Other areas of research-need include development of risk-adjustment methods to accurately compare outcomes of clinical preventive services, and development of outcomes measures that incorporate functional assessment.
Quality Quality issues include timeliness, appropriateness of technique or procedure, avoidance of harm from the service, and relevance of the technique/procedure to the recipient. Many organizations are refining and formalizing reliable and accurate quality measures. Often ambulatory care quality assessments are based on analysis of administrative data or claims data and some measure of patient satisfaction. The feedback of comparative information is used as a stimulus for quality improvement. Although the administrative data- or claims-based analyses of preventive services can be broad in scope, there are limitations to the depth of analysis. Provision of services may be reported on claims, but such data provide no indication of the service’s quality. Assessment of service quality has been difficult. Research is needed to develop more meaningful and efficient methods for measuring and improving the quality of clinical preventive services. Research on quality and clinical preventive services would be useful related to the following questions: What are the best measures of the quality of clinical preventive services? What is the comparative validity of patient reports, chart review, facility report cards, or claims data for different preventive services? How can quality-of-service measures be standardized for fair comparison? What are the best methods to ensure that follow-up of abnormal screening test results is timely; for example, how can the follow-up process be improved for patients with abnormal Papanicolaou tests?
Access Improved availability of preventive health care services is a generally accepted national goal for which there is little or no overt disagreement. Many factors affect access. Economic barriers certainly may reduce utilization of preventive services. For example, women without health insurance are less likely to have received a mammogram or Pap test in the last year.14,15 While preventive service affordability may improve with health care restructuring, utilization may not necessarily improve for everyone. Even with insurance coverage, other factors, not necessarily yet identified, affect utilization of preventive services. In Ontario, Canada, where universal health insurance coverage has been present for many years, rates of mammography and Pap testing are below the U.S. average, and low income, as in the United States, is associated with non-use.16 In the United States, Medicare covers mammography for eligible beneficiaries. Even with Medicare, women generally are required to make a co-payment. One study found that lack of supplemental insurance to cover co-payments was associated with much lower use of mammography.17 While the study adjusted for some demographic variables, it could not evaluate education and knowledge. Lack of knowledge about preventive measures was a greater barrier than cost in another study.18 Provider gender was associated with preventive care in another study—females were more likely to undergo Pap testing and mammography if they saw a female physician.19 Physician advice to have a mammogram done is associated with having the test done.20 Getting physician behavior to change, i.e., to incorporate more preventive services, requires more than physician education.21 Reducing preventive service access barriers may require a comprehensive preventive health systems management approach. In this sense, a preventive health system can be viewed as the sum of available resources for preventive services, and the organization, prioritization, and implementation of those resources. Systems management research may help determine the appropriate infrastructure and personnel needs for delivering clinical preventive services.22 If delivery system restructuring reduces financial barriers, there may be more demand for both acute care and preventive health services. Preventive services that must be provided by physicians may not receive as much attention by either patients or physicians as treatment services.23 Competing demand for treatment services from physician providers may cause provision of preventive services to decline. New strategies to use nonphysician providers for clinical preventive services may be needed to increase capacity, and preserve or increase access to preventive services. For example, the feasibility of nurses performing screening sigmoidos-
Am J Prev Med 1998;14(4)
333
copy, as part of a team in a controlled system, has recently been demonstrated.24 Technologic support also may increase access to clinical preventive health services. A computer-assisted information management system may be useful.25,26 Health systems management research can define methods for integrating computer techniques into a comprehensive health plan for delivering preventive services. Other useful research would include comparisons of technologic support in different managed care systems and identification of the organizational characteristics that improve the delivery of preventive services. Because people may seek care for acute services more readily than for preventive services, comparisons of methods to increase the delivery of recommended clinical preventive services for those who come in for other health care and fail to get preventive services (missed opportunities) would be useful. AHCPR continues to encourage health services research in all these areas. Improvement in the efficiency, quality, and access to clinical preventive services is an Agency, as well as a national, goal.
References 1. Relman AS. Assessment and accountability: the third revolution in medical care. N Engl J Med 1988;319: 1220 –2. 2. Iglehart JK. The National Committee for Quality Assurance. N Engl J Med 1996;335:995–9. 3. Leutwyler K. The Price of prevention. Sci Am April 1995;124 –9. 4. Frame PS, Werth PL. How primary health care providers can integrate cancer prevention into practice. Cancer 1993;72(3 Suppl):1132–7. 5. Ornstein SM, Musham C, Reid A, Jenkins RG, Zemp LD, Garr DR. Barriers to adherence to preventive services reminder letters: the patient’s perspective. J Fam Pract 1993;36:195–200. 6. Selby ML, Riportella-Muller R, Sorenson JR, Quade D, Luchok KJ. Increasing participation by private physicians in the EPSDT Program in rural North Carolina. Public Health Rep 1992;107:561– 8. 7. Health Services Research on Clinical Preventive Services. Grant Announcement. NIH Guide for Grants and Contracts. Washington, DC; 1994;23(24). 8. Office of Technology Assessment, Congress of the United States. Assessing the Efficacy and Safety of Medical Technologies. Washington, DC; September 1978. 9. Guide to Clinical Preventive Services. Report of the US Preventive Services Task Force. 2nd ed. Washington, DC: U.S. Dept. of Health and Human Services, Office of Public Health and Science. GPO; 1996:415–220.
334
10. Sox HX, Woolf SH. Evidence-based practice guidelines from the U.S. Preventive Services Task Force. JAMA 1993;269:2678. 11. Ganiats TG. On sale: future health care. The paradox of discounting. West J Med 1992;156:550 –3. 12. Redelmeier DA, Heller DN. Time preferences in medical decision making and cost-effectiveness analysis. Medical Decision Making 1993;13:212–7. 13. Chapman GB, Elstein AS. Valuing the future: temporal discounting of health and money. Medical Decision Making. 1995;15:373– 86. 14. Hopkins RS. Insurance coverage and usage of preventive health services. J Fla Med Assoc 1993;80:529 –32. 15. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Advance Data no. 254, Vital and Health Statistics of CDC. Hyattsville, Maryland; August 3, 1994. 16. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage. JAMA 1994; 272:530 – 4. 17. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med 1995;332:1164 – 8. 18. Elnicki DM, Morris DK, Shockcor WT. Patient-perceived barriers to preventive health care among indigent, rural Appalachian patients. Arch Intern Med 1995;155:421– 4. 19. Lurie N, Slater J, McGovern P, Ekstrum J, et al. Preventive care for women. Does the sex of the physician matter? N Engl J Med 1993;329:478 – 82. 20. Glanz K, Resch N, Lerman C, Blake A, Gorchov PM, Rimer BK. Factors associated with adherence to breast cancer screening among working women. J Occup Med 1992;34:1071– 8. 21. Elford RW, Jennett P, Bell N, Szafran O, Meadow L. Putting prevention into practice. Health Rep 1994;6:142– 53. 22. Kottke TE, Brekke ML, Solberg LI. Making “time” for preventive services. Mayo Clin Proc 1993;68:785–91. 23. Jae´n CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166 –71. 24. Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330:183–7. 25. Elford RW, Yeo M, Jennett PA, Sawa RJ. A practical approach to lifestyle change counselling in primary care. Patient Educ Couns 1994;24:175– 83. 26. Burack RC, Gimotty PA, George J, Stengle W, Warbasse L, Moncrease A. Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care 1994;32:609 –24.
American Journal of Preventive Medicine, Volume 14, Number 4
Medical Subject Headings (MeSH): preventive health services, Agency for Health Care Policy and Research (AHCPR), cost effectiveness, quality assessment (health care). (Am J Prev Med 1998;14:331–334) © 1998 American Journal of Preventive Medicine
D
uring the national health care reform debate in the 103rd Congress, all major proposals included specific clinical preventive services as important and explicitly defined benefits. The proposed Health Security Act, for example, carefully defined a benefit package with selected clinical preventive services. Even more modest proposals frequently specified elimination of co-payments for preventive care. While no health care reform legislation was passed by the 103rd Congress, support for preventive services, in one way or another, was one of the few nearly universally accepted goals. Today, health care purchasers and consumers appear to be demanding more accountability in health care delivery systems.1 There is growing interest in reporting health care plan performance, including performance of clinical preventive services. For example, the Healthplan Employer Data and Information System (HEDIS) is used by many managed care plans, and is being required for Medicare managed care plans.2 HEDIS includes data on a significant number of clinical preventive services, such as immunizations, mammography, lipid screening, and cervical cancer screening. Comparisons among plans can be made by potential purchasers and consumers. Plans are competing in terms of clinical prevention as well as acute care services and cost. A new focus on these preventive services is provided by the rapid increase in the proportion of Americans receiving care in organized delivery systems. Although other services, such as counseling and injury prevention, have not received the same attention, preventive care, nevertheless, remains in the national spotlight. Health care organizations that are accountable for providing care to a defined population would appear to have a vested interest in shifting the focus of medical care to one that keeps individuals as healthy as possible. Center for Primary Care Research, Agency for Health Care Policy and Research, Rockville, Maryland 20852. Address correspondence to: Dr. James K. Cooper, CPCR/AHCPR, 2101 E. Jefferson Street, Rockville, Maryland 20852.
Am J Prev Med 1998;14(4) © 1998 American Journal of Preventive Medicine
On the other hand, rapid enrollee turnover may lessen managed care’s interest in preventive services, as the benefits may not accrue until years later, when the enrollee may be in another plan. Fierce competition among plans may require them to focus on current cost reduction rather than on long-term benefits. And even if they did focus on future costs, preventive services do not always produce reduced health care costs.3 Preventive services may not expand under managed care unless they are both demanded by purchasers, and can be provided at reasonable cost. While there appears to be national interest in making preventive services widely available, there is, then, also great interest in making them efficient, i.e., making them produce the most good for the least cost. This goal fits into the rubric of health services research. The Agency for Health Care Policy and Research (AHCPR) is the lead agency for health services research in the Department of Health and Human Services. Building on a foundation established by its predecessor, the National Center for Health Services Research, AHCPR has supported studies that identify ways to increase the delivery and efficiency of recommended clinical preventive services.4 In general, clinical preventive services are prevention services offered or initiated in the personal health care setting. Examples include immunizations, disease screening, counseling to reduce health risks, and chemoprophylaxis after exposure to infectious disease. AHCPR-supported studies have focused on a variety of clinical preventive services issues. One study examined barriers to receiving preventive services.5 Another AHCPR-supported study explored ways to increase private physician participation in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, helping to bring the benefits of a public prevention program to children seen in physicians’ offices.6 Other AHCPR-supported studies currently underway include the development of strategies to encourage primary care practitioners to increase the provision of recommended prevention services.
0749-3797/98/$19.00 PII S0749-3797(97)00056-1
331
As the rapid shift to organized systems of care heightens interest in the delivery of clinical preventive services, AHCPR invites researchers to submit proposals that further this purpose by helping translate diseaseprevention knowledge into improved and more efficient clinical preventive services.7 As health care evolves, a diversity of approaches to clinical preventive services can be expected. This offers a setting for many natural experiments, and researchers should have many opportunities to evaluate benefits of new approaches.
Research Goals AHCPR is interested in effectiveness research. The framework separating “effectiveness” from “efficacy” dates back to at least 1978, when the Office of Technology Assessment issued a report on the efficacy and safety of medical technologies.8 In this framework, “efficacy” refers to the probability of benefit under ideal conditions, and “effectiveness” refers to benefit that can be expected in typical “everyday” situations. This framework has been useful in separating clinical research into two categories and helps align investigators with appropriate funding agencies. While not all federal agencies dichotomize clinical research this way (the Food and Drug Administration has a broad definition of effectiveness that includes efficacy), AHCPR encourages health services research proposals on efficacy-proven clinical preventive services, not research on preventive services for which efficacy has not yet been established. Factors that can change the probability of benefit of interventions “in the real world,” and thus also their effectiveness, include provider behaviors, skills, and techniques; and patient adherence/compliance and other characteristics. Organizational characteristics such as context, institutional values, incentives, control, and external relationships may affect the benefit of preventive services by increasing the proportion of targeted people receiving the intervention. Organizational characteristics may also affect costs. Recommendations for clinical preventive services are presented in the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services.9 The U.S. Preventive Services Task Force was established in 1984 to develop evidence-based guidelines for preventive care, and their recommendations provide a blueprint for action.10 While efficacy of these clinical preventive services is generally accepted, the aggregate community benefit of many prevention programs has been disappointing. AHCPR hopes to support research that leads to improved effectiveness and efficiency of clinical preventive services in the community. Research is sought in three areas. These areas are interrelated, and research may address one, two, or all three areas.
332
Effectiveness and Cost-Effectiveness There is no question that cost has become an important consideration in the delivery of health care. It is unrealistic to imagine that all preventive services should be offered to all individuals. Cost constraints and movement toward competitive contracting for clinical services increase the need for reliable and acceptable cost-effectiveness data. Groups that purchase or pay for health care, such as corporations and purchaser alliances, need information on the effectiveness and costs of preventive services, and the way they are provided, in order to make informed decisions as to what to purchase. Provider groups need information about effectiveness and ways to lower the costs of individual preventive services. Coverage for services, components of bundled services, and exclusions of services may be determined on the basis of cost-effectiveness and outcomes analyses. Cost-effectiveness studies examine the cost of alternatives to achieve a desired goal. Costs include direct medical costs and indirect costs, which include psychological costs. Psychological costs may include pain, fear, apprehension, and perhaps loss of gratifying behaviors. Effectiveness relates to patient outcomes, and may include outcomes other than morbidity or mortality, such as functional status and quality of life. Cost savings from preventive services are particularly difficult to evaluate, because the expected gain from an intervention may be in the extended future, and many other variables are likely to intervene. The value of a future savings is difficult to assess due to disagreement on discounting.11 The public’s discount rates for some serious outcomes, such as colostomy and blindness, are much less than the usual discount rates used by economists, meaning people assign a high value to avoiding them in the future as well as the present. But discount rates also have shown dynamic inconsistency bias; discounts for long delays can be lower than for short delays.12,13 In other words, in some cases, individuals appear to value a health benefit more in the distant future than in the near future. Understanding how people value their future health can assist in planning clinical preventive programs that preserve future health. Important research in this area would include: costeffectiveness of specific preventive services; cost-effectiveness comparison of practice standards and recommendations, comparing different methods for the delivery of preventive services currently suggested by various organizations; and effects of different practice management patterns on cost-effectiveness of clinical preventive services. Another important research issue is the cost-effectiveness of different approaches to counseling and health
American Journal of Preventive Medicine, Volume 14, Number 4
education services. An example is the question, how useful are approaches that use non-physician providers? Corporate and other large purchasers may negotiate with provider groups for “packages” of preventive services. The services may be “bundled” for consideration. Evaluation of bundling preventive services, including cost-effectiveness of various preventive service packages, is an important topic. The interaction of combinations of services is virtually unstudied. For example, does an intense cholesterol control program have any effect on a simultaneous cancer control program? In addition to dollar costs, preventive services should be evaluated in other dimensions as well. Methods for assessing outcomes of clinical preventive services that incorporate quality-of-life measures and patient preferences into standardized methods of comparison are important. Other areas of research-need include development of risk-adjustment methods to accurately compare outcomes of clinical preventive services, and development of outcomes measures that incorporate functional assessment.
Quality Quality issues include timeliness, appropriateness of technique or procedure, avoidance of harm from the service, and relevance of the technique/procedure to the recipient. Many organizations are refining and formalizing reliable and accurate quality measures. Often ambulatory care quality assessments are based on analysis of administrative data or claims data and some measure of patient satisfaction. The feedback of comparative information is used as a stimulus for quality improvement. Although the administrative data- or claims-based analyses of preventive services can be broad in scope, there are limitations to the depth of analysis. Provision of services may be reported on claims, but such data provide no indication of the service’s quality. Assessment of service quality has been difficult. Research is needed to develop more meaningful and efficient methods for measuring and improving the quality of clinical preventive services. Research on quality and clinical preventive services would be useful related to the following questions: What are the best measures of the quality of clinical preventive services? What is the comparative validity of patient reports, chart review, facility report cards, or claims data for different preventive services? How can quality-of-service measures be standardized for fair comparison? What are the best methods to ensure that follow-up of abnormal screening test results is timely; for example, how can the follow-up process be improved for patients with abnormal Papanicolaou tests?
Access Improved availability of preventive health care services is a generally accepted national goal for which there is little or no overt disagreement. Many factors affect access. Economic barriers certainly may reduce utilization of preventive services. For example, women without health insurance are less likely to have received a mammogram or Pap test in the last year.14,15 While preventive service affordability may improve with health care restructuring, utilization may not necessarily improve for everyone. Even with insurance coverage, other factors, not necessarily yet identified, affect utilization of preventive services. In Ontario, Canada, where universal health insurance coverage has been present for many years, rates of mammography and Pap testing are below the U.S. average, and low income, as in the United States, is associated with non-use.16 In the United States, Medicare covers mammography for eligible beneficiaries. Even with Medicare, women generally are required to make a co-payment. One study found that lack of supplemental insurance to cover co-payments was associated with much lower use of mammography.17 While the study adjusted for some demographic variables, it could not evaluate education and knowledge. Lack of knowledge about preventive measures was a greater barrier than cost in another study.18 Provider gender was associated with preventive care in another study—females were more likely to undergo Pap testing and mammography if they saw a female physician.19 Physician advice to have a mammogram done is associated with having the test done.20 Getting physician behavior to change, i.e., to incorporate more preventive services, requires more than physician education.21 Reducing preventive service access barriers may require a comprehensive preventive health systems management approach. In this sense, a preventive health system can be viewed as the sum of available resources for preventive services, and the organization, prioritization, and implementation of those resources. Systems management research may help determine the appropriate infrastructure and personnel needs for delivering clinical preventive services.22 If delivery system restructuring reduces financial barriers, there may be more demand for both acute care and preventive health services. Preventive services that must be provided by physicians may not receive as much attention by either patients or physicians as treatment services.23 Competing demand for treatment services from physician providers may cause provision of preventive services to decline. New strategies to use nonphysician providers for clinical preventive services may be needed to increase capacity, and preserve or increase access to preventive services. For example, the feasibility of nurses performing screening sigmoidos-
Am J Prev Med 1998;14(4)
333
copy, as part of a team in a controlled system, has recently been demonstrated.24 Technologic support also may increase access to clinical preventive health services. A computer-assisted information management system may be useful.25,26 Health systems management research can define methods for integrating computer techniques into a comprehensive health plan for delivering preventive services. Other useful research would include comparisons of technologic support in different managed care systems and identification of the organizational characteristics that improve the delivery of preventive services. Because people may seek care for acute services more readily than for preventive services, comparisons of methods to increase the delivery of recommended clinical preventive services for those who come in for other health care and fail to get preventive services (missed opportunities) would be useful. AHCPR continues to encourage health services research in all these areas. Improvement in the efficiency, quality, and access to clinical preventive services is an Agency, as well as a national, goal.
References 1. Relman AS. Assessment and accountability: the third revolution in medical care. N Engl J Med 1988;319: 1220 –2. 2. Iglehart JK. The National Committee for Quality Assurance. N Engl J Med 1996;335:995–9. 3. Leutwyler K. The Price of prevention. Sci Am April 1995;124 –9. 4. Frame PS, Werth PL. How primary health care providers can integrate cancer prevention into practice. Cancer 1993;72(3 Suppl):1132–7. 5. Ornstein SM, Musham C, Reid A, Jenkins RG, Zemp LD, Garr DR. Barriers to adherence to preventive services reminder letters: the patient’s perspective. J Fam Pract 1993;36:195–200. 6. Selby ML, Riportella-Muller R, Sorenson JR, Quade D, Luchok KJ. Increasing participation by private physicians in the EPSDT Program in rural North Carolina. Public Health Rep 1992;107:561– 8. 7. Health Services Research on Clinical Preventive Services. Grant Announcement. NIH Guide for Grants and Contracts. Washington, DC; 1994;23(24). 8. Office of Technology Assessment, Congress of the United States. Assessing the Efficacy and Safety of Medical Technologies. Washington, DC; September 1978. 9. Guide to Clinical Preventive Services. Report of the US Preventive Services Task Force. 2nd ed. Washington, DC: U.S. Dept. of Health and Human Services, Office of Public Health and Science. GPO; 1996:415–220.
334
10. Sox HX, Woolf SH. Evidence-based practice guidelines from the U.S. Preventive Services Task Force. JAMA 1993;269:2678. 11. Ganiats TG. On sale: future health care. The paradox of discounting. West J Med 1992;156:550 –3. 12. Redelmeier DA, Heller DN. Time preferences in medical decision making and cost-effectiveness analysis. Medical Decision Making 1993;13:212–7. 13. Chapman GB, Elstein AS. Valuing the future: temporal discounting of health and money. Medical Decision Making. 1995;15:373– 86. 14. Hopkins RS. Insurance coverage and usage of preventive health services. J Fla Med Assoc 1993;80:529 –32. 15. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Advance Data no. 254, Vital and Health Statistics of CDC. Hyattsville, Maryland; August 3, 1994. 16. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage. JAMA 1994; 272:530 – 4. 17. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med 1995;332:1164 – 8. 18. Elnicki DM, Morris DK, Shockcor WT. Patient-perceived barriers to preventive health care among indigent, rural Appalachian patients. Arch Intern Med 1995;155:421– 4. 19. Lurie N, Slater J, McGovern P, Ekstrum J, et al. Preventive care for women. Does the sex of the physician matter? N Engl J Med 1993;329:478 – 82. 20. Glanz K, Resch N, Lerman C, Blake A, Gorchov PM, Rimer BK. Factors associated with adherence to breast cancer screening among working women. J Occup Med 1992;34:1071– 8. 21. Elford RW, Jennett P, Bell N, Szafran O, Meadow L. Putting prevention into practice. Health Rep 1994;6:142– 53. 22. Kottke TE, Brekke ML, Solberg LI. Making “time” for preventive services. Mayo Clin Proc 1993;68:785–91. 23. Jae´n CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166 –71. 24. Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330:183–7. 25. Elford RW, Yeo M, Jennett PA, Sawa RJ. A practical approach to lifestyle change counselling in primary care. Patient Educ Couns 1994;24:175– 83. 26. Burack RC, Gimotty PA, George J, Stengle W, Warbasse L, Moncrease A. Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care 1994;32:609 –24.
American Journal of Preventive Medicine, Volume 14, Number 4